Computers & Industrial Engineering 137 (2019) 106005

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Computers & Industrial Engineering

journal homepage: www.elsevier.com/locate/caie

Factors influencing medical tourism adoption in Malaysia: A DEMATEL- T

Fuzzy TOPSIS approach
Mehrbakhsh Nilashia,b, , Sarminah Samadc, Azizah Abdul Manafd, Hossein Ahmadie,
⁎

Tarik A. Rashidf, Asmaa Munshid, Wafa Almukadih, Othman Ibrahimg, Omed Hassan Ahmede
a
Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Viet Nam
b
Faculty of Information Technology, Ton Duc Thang University, Ho Chi Minh City, Viet Nam
c
Department of Business Administration, Collage of Business and Administration, Princess Nourah Bint Abdulrahman University, Saudi Arabia
d
Department of Cybersecurity, College of Computer Science and Engineering, University of Jeddah, Jeddah, Saudi Arabia
e
Department of Information Technology, University of Human Development, Sulaymaniyah, Iraq
f
Computer Science and Engineering Department, University of Kurdistan Hewler, Erbil, Kurdistan, Iraq
g
Azman Hashim International Business School, Universiti Teknologi Malaysia (UTM), Skudai, Johor 81310, Malaysia
h
Department of Software Engineering, College of Computer Science and Engineering, University of Jeddah, Jeddah, Saudi Arabia

ARTICLE INFO ABSTRACT

Keywords: Tourism is one of the biggest competitive industries in the world. Nowadays, medical tourism is quickly de-
Medical tourism veloping as a part of tourism for health and wellness care. There are many factors influencing the development of
Medical hotels medical tourism in developing countries. This research aims to identify those factors for medical tourism de-
Decision-making velopment in Malaysia. We investigate the factors from the literature to develop a new decision-making model.
Health tourism
We use two multi-criteria decision making techniques, Decision Making Trial and Evaluation Laboratory
Readiness
DEMATEL
(DEMATEL) and Fuzzy Order of Preference by Similarity to Ideal Solution (Fuzzy TOPSIS), to reveal the inter-
Fuzzy TOPSIS relationships among the factors and to find the relative importance of these factors in the decision making
model. The results showed that human and technological factors are the most important factors for medical
tourism adoption in Malaysia. The results of this study will enable key players in the medical tourism industry to
potentially assign investments for medical tourism in the developing countries.

1. Introduction
Tourism is one of the fastest growing industries in the world (Ahani,
Nilashi, Ibrahim, Sanzogni, & Weaven, 2019; Nilashi, Ahani et al.,
2019; Nilashi, Yadegaridehkordi et al., 2019). As a new form of
tourism, health tourism has become one of the fastest growing inter-
national businesses in the tourism industry for developing countries.
Medical tourism is defined as “the act of traveling abroad to obtain
medical care” (Keckley, 2008, p. 4). Medical tourism has been emerging
as a particularly lucrative sector, potential tourist market and global
phenomenon in health care. The evidence shows that many developing
countries such as Thailand, Malaysia and India attracted more than two
and a half million medical tourists in 2005 (Heung, Kucukusta, & Song,
2011). In Asia, Singapore, Thailand, and Malaysia, India, the Phi-
lippines, South Korea and Taiwan have been the major countries for
international medical travelers for medical tourism services.
Readiness is defined as the “people’s propensity to embrace and use
new technologies for accomplishing goals in home life and at work”
(Parasuraman, 2000). In another definition cited by Shea, Jacobs,
Esserman, Bruce, and Weiner (2014), organizational readiness refers to
“the extent to which organizational members are psychologically and
behaviorally prepared to implement organizational change” (Weiner,
Lewis, & Linnan, 2008). To be new innovation in organizations savvy,
the organizations need to be ready from different aspects to employ it
for their competitive advantage in the business (Parasuraman & Colby,
2015). It has been shown that establishing sufficient organizational
readiness is an essential step of implementing new programs, practices,
or policies in organizations (Asadi et al., 2019; Shea et al., 2014). In
addition, it has been found that there is a positive relationship between
the organizational readiness and the willingness of members to initiate
change, exert greater effort and cooperative behaviour (Weiner et al.,
2008), which accordingly will result in more effective and successful
implementation of the proposed new innovation.
Although there have been several attempts for medical tourism in

⁎
Corresponding author at: Department for Management of Science and Technology Development, Ton Duc Thang University, Ho Chi Minh City, Viet Nam.
E-mail address: nilashi@tdtu.edu.vn (M. Nilashi).

https://doi.org/10.1016/j.cie.2019.106005

Available online 03 August 2019

0360-8352/ © 2019 Elsevier Ltd. All rights reserved.
M. Nilashi, et al.
Malaysia, however, according to Malaysia Healthcare Travel Council
(MHTC), the medical tourism industry in this country still needs a lot of
improvements in order to be the regional hub for the international
tourist medical services. In addition, there are many barriers in
Malaysia which still need to be overcome to foster medical tourism
growth and compete in this field (Sarwar, 2013). Furthermore, to
achieve a high success rate, improve the country ranking in medical
tourism and compete in this field, many Malaysian medical tourism
stakeholders need to provide a world class service with effective in-
formation services and adopt a different strategy for medical tourists.
The evidence shows that many stakeholders are not yet capable of
providing medical tourist services for the shortage of human resource in
the health sector (Manaf & Hazilah, 2010). In fact, they are not able to
take fully the advantages of medical tourism because of several en-
vironmental, technological, organizational and human issues to meet
this sector of tourism.
In this research, we develop a decision making model and propose
by four readiness factors which are all essential for the adoption of
medical tourism in developing countries. We then use two multi-criteria
decision making techniques, Decision Making Trial and Evaluation
Laboratory (DEMATEL) and Fuzzy Order of Preference by Similarity to
Ideal Solution (Fuzzy TOPSIS), to reveal the interrelationships among
the factors and find the their ranks in the decision making model. We
show that if tourism companies are not ready from those aspects of
readiness, they may become hesitant to adopt medical tourism in their
organizations. Accordingly, the main research question which this
study investigates is: what factors influence medical tourism adoption
in Malaysia? Overall, the contributions of this research are as follows:
(i) We develop a new model for medical tourism adoption through
Human, Organization and Technology fit (HOT-fit) and
Technology, Organization and Environment (TOE) framework.
These organizational theories have been widely used in healthcare
management studies (Ahmadi, Ibrahim, & Nilashi, 2015; Ahmadi,
Nilashi, & Ibrahim, 2015; Ahmadi, Nilashi, Shahmoradi, &
Ibrahim, 2017; Nilashi, Ahmadi, Ahani, Ravangard, & bin Ibrahim,
2016).
(ii) In contrast with the previous studies which are from the customers’
perspectives, the proposed model is based on hotel managers’
perspectives in Malaysia. Accordingly, the data is collected from
the managers of major hotels who had experiences in hotel man-
agement and operations.
(iii) This study uses two multi-criteria decision making techniques,
DEMATEL and Fuzzy TOPSIS, for analysis the data collected from
the managers of hotels. As effective multi-criteria decision making
techniques, DEMATEL and Fuzzy TOPSIS are widely used in a
variety of decision-making problems (Fu & Liao, 2019; Zhu, Luo,
Liao, Zhang, & Shen, 2019).
This research is organized as following. Section 2 presents the
proposed framework. A brief description of the methods used for data
analysis is presented in Section 3. Discussions on the results are pro-
vided in Section 4. Finally, the conclusions and future study are pre-
sented in Section 5.
2. Model development
In the following sections, the previous studies on medical tourism
are discussed. In addition, the proposed model for medical tourism
adoption is presented.
2.1. Previous work on medical tourism
In a study by Tham (2018), the authors explored the domestic
medical tourism developments in Australia. The findings of this re-
search showed that lack of cooperation, residents' access to hospital
2
Computers & Industrial Engineering 137 (2019) 106005
facilities and hostile attitudes between practitioners are the main bar-
riers for the domestic medical tourism development. Their findings
were obtained from seven different stakeholder groups. de la Hoz-
Correa, Muñoz-Leiva, and Bakucz (2018) conducted a study on Web of
Science and Scopus databases to investigate the evolution of medical
tourism from the longitudinal perspective. Six clusters of themes were
found in their study which are: “health-related issues, medical treat-
ments and tourism”; “medical tourism destinations and marketing”;
“sensitive practices in medical tourism”; “globalization, policies”;
“ethical implications”, “trust and accreditation”; “health, wellness, spa
tourism and service quality and the effect on international patients”.
Ganguli and Ebrahim (2017) conducted a qualitative approach for
the identification and analyzing the factors for medical tourism desti-
nation in Singapore. They found seven pillars for Singapore's medical
tourism competitiveness, “an enabling tourism sector”, “strategic
planning”, “PPPS frameworks”, “marketing and branding strategies”,
“marketing and branding strategies”, “accreditation & governance”,
“accreditation & governance” and “human capital development”.
Esiyok, Çakar, and Kurtulmuşoğlu (2017) investigated the effect of
cultural distance on medical tourism. Their study measured cultural
distance based on Hofstede's cultural framework, used panel data, in-
cluded neighbouring countries in the sample, and aggregated the data
at the specialty level. Their empirical findings provided by the baseline
model indicated that the incorporation of cultural distance is important
in policy planning in medical tourism.
Majeed, Lu, and Javed (2017) conducted a scoping review on health
systems and medical tourism. They included 112 papers in their review.
Fetscherin and Stephano (2016) presented a medical tourism index to
evaluate the attractiveness of a country to be a host for medical tourists.
Using a rigorous multi-steps scale, they conducted the work from four
empirical studies which included 4995 respondents. Beladi, Chao, Ee,
and Hollas (2015) focused on medical tourism and investigated the
income distribution effects of medical tourism in developing countries.
They found that that an expansion of medical tourism in the countries
can have favorable and unfavorable economic implications. Lunt,
Horsfall, and Hanefeld (2016) conducted a review on medical tourism.
They used WoS and British Library Search in their review. The search
terms were: Cosmetic tourism, Medical tourism, Treatment abroad,
Treatment overseas, Cosmetic surgery, Cross-border fertility, abroad,
Dental tourism, Medical vacation and Cross-border health, Cosmetic
surgery overseas, Surgery abroad, Transplant tourism, Fertility tourism
and Medical travel.
Two areas of medical tourism (i.e., cosmetic and dental procedures),
were investigated by Rodrigues, Brochado, Troilo, and Mohsin (2017).
They used Leximancer software to analysis the postprocedural experi-
ences of 603 medical tourists. The medical tourists were from different
countries between 2008 and 2016. Chuang, Liu, Lu, and Lee (2014)
developed a study on medical tourism and used the main path analysis
to analyze active research areas in medical tourism, literature, and the
development trajectories. Runnels and Carrera (2012) enhanced the
knowledge on medical tourism and proposed a sequential decision
making process. They found that the identification of need is the first
step in the sequence of a typical decision making process to engage in
medical tourism. In medical tourism, the experiences of informal
caregivers were investigated by Whitmore, Crooks, and Snyder (2015)
through a semi-structured interview with 20 Canadians who their fa-
mily members or friends had experiences in abroad surgery as medical
tourist. They asked the questions regarding the members experiences
prior to, during and after travel in their surgery. From the thematic
analysis by the use of NVivo software, they found three themes central
to an ethics of care: mutuality, responsibility and vulnerability.
Frederick and Gan (2015) investigated the East–West differences
among the websites of medical tourism facilitators. They used logistic
regressions in their data analysis. In medical tourism, Mohamad, Omar,
and Haron (2012) investigated the moderating impact of medical travel
facilitators. They found the important role of medical travel facilitators
M. Nilashi, et al.
for prospective patients and hospital providers.
Crush and Chikanda (2015) investigated the South-South medical
tourism and the quest for health in Southern Africa. Connell (2013)
found the culture, quality and availability of care influence medical
tourism behaviour. Sarantopoulos, Vicky, and Geitona (2014) in-
vestigated the tourist executives’ opinions, beliefs and aspects in med-
ical tourism in Greece. They examined the factors which impact the
tourist potential investments on medical tourism. They focused on two
types of medical tourism, non-cosmetic surgery and medical treatment.
They used logistic regression in their data analysis. Lee and Fernando
(2015) focused on medical tourism supply chain by investigating the
antecedents and outcomes. Accordingly, they proposed a theoretical
model and evaluated the model though PLS-SEM. They selected 133
organizations as medical tourism providers in Malaysia and collected
the data using a self-administered questionnaire. They investigated fi-
nancial and non-financial organizational performance in their study.
The results of their work revealed the importance of mutual de-
pendency on antecedent variables.
Heung et al. (2011) determined the factors impacting on the de-
velopment of medical tourism in Hong Kong. They identified the costs,
expertise/manpower, infrastructural and super-structural factors, po-
licies and regulations, promotion, facilities and attractions, government
attitude, communication, and investment potential as the main barriers
to medical tourism development. Their data collection was from the
medical institutions, the government bodies, and the representatives of
private and public hospital. They used a qualitative research technique
for data collection. Costs, capacity problems, government support, po-
licies and regulations and the healthcare needs of the local community
were the most important barriers of developing the medical tourism in
Hong Kong. Moghavvemi et al. (2017) examined the private hospitals
websites which aimed to promote medical tourism in Thailand, India
and Malaysia. The authors analysed the content and format of web-
pages of 51 hospitals through five factors: interactive online services,
admission and medical services, technical items, external activities and
hospital Information and facilities. Offering interactive online services
was the most important weakness of hospital websites across the three
countries to provide medical tourism services.
Bies and Zacharia (2007) developed an Analytic Network Process
(ANP) model to determine how medical tourism services can be effec-
tively encouraged. The strategic criteria in their ANP model were:
“Condition of Domestic Health Care System”, “Universality of Access of
Health Care” and “Quality of Healthcare”. They also considered “Ben-
efits”, “Opportunities”, “Costs” and “Risks Analysis” with the strategic
criteria. They found that self-selected medical tourism is preferred in
relation to the employer- or government-sponsored programs and over
the status quo, as it involves lower cost. They also found government-
encouraged medical tourism as the least preferred option. In the Ca-
nadian healthcare system, Sheppard, Lester, Karmali, de Gara, and
Birch (2014) investigated the cost of bariatric medical tourism. They
selected 62 patients who had been medical tourists, between February
2009 and June 2013. Khan and Alam (2014) investigated the medical
tourism in Saudi Arabia. They emphasized that Saudi Arabia has sig-
nificant capability to become a hub of medical tourism in the region.
Buzinde and Yarnal (2012) investigated the therapeutic landscapes and
postcolonial theory in medical tourism. They showed that therapeutic
landscapes are able to facilitate the medical tourism sites. Abubakar
and Ilkan (2016) investigated the impact of online Word-of-Mouth
(WoM) on destination trust and intention to travel in medical tourism.
They also investigated the moderating effect of income in their study.
The authors provide a model and conducted a survey with outbound
medical tourists who visited Turkey for medical services. They found
the importance of online WoM on destination trust and accordingly
intention to travel. They also found that the relationship between WoM
and intention to travel can be strengthened by income.
3
Computers & Industrial Engineering 137 (2019) 106005
Hallem and Barth (2011) investigated the customer-perceived value
of medical tourism in Tunisia by developing an exploratory study for
cosmetic surgery. They showed the importance of cost as a major in-
centive in medical tourism. Han and Hyun (2015) studied the customer'
retention in medical tourism. They investigated the impact of price
reasonableness, satisfaction, trust, and quality. They considered Per-
ceived Service Quality, Customer Satisfaction, Trust in the Staff, Per-
ceived Medical Quality, Intention to Revisit, Trust in the Clinic, and
Intention to Revisit Korea for Medical Care in their model. They con-
ducted a field survey at medical clinics.
Yu and Ko (2012) developed a cross-cultural study on medical
tourism to reveal the perceptions of Korean, Japanese and Chinese
tourists in Korea. The aim was to identify cultural differences among
these countries. This research established four factor groups (Selective
factors, Inconveniences, Medical treatments and Well-being and
healthcare) for medical tourism through an exploratory factor analysis.
Crooks, Turner, Snyder, Johnston, and Kingsbury (2011) conducted a
study in medical tourism to identify and understand the messages and
images which are used by companies use for the marketing purpose in
India as a global destination. Smith, Álvarez, and Chanda (2011) in-
vestigated the role of bi-lateral trade for medical tourism. They used
UK–India as a case study. Viladrich and Baron-Faust (2014) examined
the online marketing literature for cosmetic surgeries in Argentina.
They argued that the role of Internet advertising should be further in-
vestigated for medical tourism in Argentina. Aziz, Yusof, Ayob, Bakar,
and Awang (2015) conducted a study to measure the tourists’ beha-
vioural intention in Malaysian medical tourism industry.
Moghimehfar and Nasr-Esfahani (2011) examined the factors im-
pacting destination choice in infertile couples who visited Isfahan, Iran.
Their investigation was based on field evaluation through documentary
survey and interview questionnaire. Chang, Chou, Yeh, and Tseng
(2016) proposed a research model to investigate the factors impacting
the Chinese patients’ intention to use the Taiwan Medical Travel App.
They used the questionnaires and statistical analyses to verify the re-
search model. They found the importance of perceived usefulness, app
involvement, and perceived ease of use in patients’ intention to use the
Taiwan Medical Travel App. Hanefeld, Lunt, Smith, and Horsfall (2015)
investigated the impact of the networks on medical travel. They found
that the majority of medical tourists have been for cosmetic, bariatric
surgery and dental treatment. In Malaysia, Yeoh, Othman, and Ahmad
(2013) conducted a nationwide study on medical tourists and found
that medical tourists are highly influenced by the doctor’s referral.
Cormany and Baloglu (2011) conducted an exploratory study to ana-
lysis the web page contents and services provided for the prospective
medical tourists. The considered two set of criteria for sites evaluation
information (e.g., email contact, mailing address, telephone number,
maps of destination served, notation of hospital accreditation, in-
formation request form, hospital selection, listing of medical proce-
dures available, past traveller testimonials, links to informational
websites, estimated treatment costs and the availability of last web page
update) and the list of services offered by the firm. The second set of
criteria was for evaluation purpose. The service areas included: ground
transportation, arrangement of medical appointments, translation ser-
vices, air travel, concierge services, transfer of medical records, site-
seeing options, hotel accommodations, provision of aftercare support
services and provision of an international cell phones.
Wongkit and McKercher (2013) examined tourists who had ex-
perience in medical treatment in Thailand. They found four different
medial tourist segments in this country. They showed that the most
medical tourists have decided to seek treatment in the destination prior
to leaving home. Han and Hwang (2013) developed a model to in-
vestigate the perceived benefits in a medical hotel and how they impact
on the international travellers’ decision making process. They in-
corporated Medical Service, Convenience, Financial Saving, Perceived
M. Nilashi, et al. Computers & Industrial Engineering 137 (2019) 106005

Value, Hospitality Product and Behavioral Intentions in their model.
Han (2013) conducted a study to identify the distinctive attributes of a
healthcare hotel. The results of their study showed the importance of
personal security among the healthcare-hotel attributes. They also
found perceptions and cognitions, trust, and affect as significant med-
iators in healthcare hotel. Turner (2011) conducted a study to empiri-
cally analysis the websites of medical tourism companies in Canada.
Chou, Kiser, and Rodriguez (2012) used expectation confirmation
theory and investigated the impact of perceived performance, sa-
tisfaction, and expectations on the tourists’ intentions to use overseas
medical services. They collected the data from 118 participants and
analyzed it using a statistical technique, Partial Least Squares (PLS).
They found that perceived overseas medical service performance has
positive impact on the overseas medical service expectation. They also
found that the medical tourists’ satisfaction can be predicted by their
confirmation of expectation. Beladi, Chao, Ee, and Hollas (2019) de-
veloped a study on the impact of medical tourism on the economic
growth through a cross-country analysis. They found that medical
tourism has a positive effect on the economic growth of host countries.
analysis the data for revealing the importance levels of factors and
finding the relationships between them in the model. The applied
methodology is introduced in the following sections.
3.1. Fuzzy TOPSIS
Multi-criteria decision making approaches are widely used in deci-
sion making problems (Büyüközkan & Çifçi, 2012; Fu & Liao, 2019; Zhu
et al., 2019). As a multi-criteria decision making approach, the Fuzzy
TOPSIS technique (Chen, 2000) has been successful in finding the best
solution under uncertainty (Wang & Elhag, 2006; Wang & Lee, 2009)
through experts' point of view (Büyüközkan & Çifçi, 2012). This study
used Fuzzy TOPSIS to find the most important factors for decision-
makers for medical tourism adoption in Malaysia. The data is collected
by TOPSIS scales as presented in Table 2. The procedure of this tech-
nique is presented as follows. For k decision makers Dr (r = 1, , k ) and
a decision-making problem with m criteria and n alternatives
Ai (i = 1, , n) , the following steps are performed to find the best cri-
teria.

2.2. Proposed model for medical tourism adoption Step 1: The weights of criteria and ratings of alternatives are ag-
gregated through the following equations:
From the previous studies, we could find that the most studies have 1 1 2 k
been conducted from the individual perspectives in medical tourism. In wj = [w j + w j + +w j ]
(1)
k
addition, it is found that the organizational readiness is not investigated
for developing countries in medical tourism. Many developing coun- x ij =
1 1 r
[x ij + x ij +
k
+x j ]
tries are still in the early stage medical tourism. In this study, however, k (2)
the success of adopting medical tourism by hotel firms is related to the j
where the weight of j th criterion (Cj ) is expressed by Wr .
readiness of an organization to provide the medical tourism services. In
addition, for any hotel firm which is planned to adopt medical tourism
Step 2: Construct the fuzzy decision matrices of the criteria and the
the questions are: (i) Is the hotel firm ready for medical tourism services?
and (ii) what are the human, organizational, technological and environ- alternative (D ) through the following equations:
mental readiness factors that impact on the decision to adopt medical
W = [w1 + w2+ + wm] (3)
tourism by hotel firms? Accordingly, this study aims to fill this gap by
providing a tripod readiness model for medical hotel adoption in
Malaysia. Here, according to medical hotel is defined a hotel that
provides foods and beverages, rooms, hotel services as well as various
aesthetic-related, healthcare, medical services to the customers. The (4)
readiness of hotel firms for healthcare services is important, as its dif-
fusion is still far from full potential due to the several readiness issues.
Step 3: Construct the normalized fuzzy decision matrix R through
In Fig. 1, we provide the framework for the hotel firms’ readiness from
the following equations:
human, organizational, technological and environmental factors. The
proposed model is based on HOT-fit and TOE framework. R = [rij ]m × n (5)
The hierarchical model includes three levels, the goal (decision to
adopt) level, the aspect levels (human, organizational, technological lij mij uij
and environmental factors) and criteria level which includes efficient rij = , , and u+j = max i uij (benefit criteria)
uij+ u+j u+j (6)
information systems (C1), internet (C2), medical technology (C3), cloud
computing technologies (C4), top management commitment (C5), fi- lj lj lj
nancial performance (C6), infrastructure (C7), international healthcare rij = , , and l j = max i lij (cost criteria)
uij mij lij (7)
collaboration (C8), government policy (C9), national healthcare policy
(C10), investment (C11), facilitating visits to malaysia (C12), language
and communication (C13), service quality (C14), specialization (C15), Step 4: Construct the weighted normalize decision matrixV through
and specialists (C16). The aim is to find which aspects of readiness can the following equation:
have significant impact on the hotel firms to adopt medical tourism
services. In addition, as provided in the research model, finding the V = [vij ]m × n , vij = xij × wj (8)
interrelationships among these aspects of readiness will also be the
contribution of this research. The factors and their criteria are pre- Step 5: Compute the Fuzzy Negative Ideal (FNIS, A ) and the Fuzzy
sented in Table 1. Positive Ideal Solution (FPIS, A+) through the following equations:
+ + +
3. Applied techniques and data analysis A+ = {v 1 , v j , , vm } (9)

In this research, we use DEMATEL and Fuzzy TOPSIS techniques to A = {v 1 , v j , , vm} (10)

4
M. Nilashi, et al. Computers & Industrial Engineering 137 (2019) 106005

Fig. 1. Proposed model for medical hotel readiness.

Table 1 Table 2
Factors and criteria for the adoption of medical tourism by hotel firms. Linguistic variables for the importance weight of each criterion.
Factors Criteria Linguistic variable Fuzzy number

Technological (D1) Efficient Information Systems (C1) “Very Low (VL)” “(0,0.05,0.15)”
Internet (C2) “Low (L)” “(0.1,0.2,0.3)”
Medical Technology (C3) “Medium Low (ML)” “(0.2,0.35,0.5)”
Cloud Computing Technologies (C4) “Medium (M)” “(0.3,0.5,0.7)”
“Medium High (MH)” “(0.5,0.65,0.8)”
Organizational (D2) Top Management Commitment (C5)
“High (H)” “(0.7,0.8,0.9)”
Financial Performance (C6)
“Very High (VH)” “(0.85,0.95,1)”
Infrastructure (C7)
International Healthcare Collaboration (C8)

Environmental (D3) Government Policy (C9)

National Healthcare Policy (C10)
Investment (C11) Table 3
Facilitating Visits to Malaysia (12)
Sample characteristics.
Human (D4) Language and Communication (C13)
Characteristics Item Number Percentage (%)
Service Quality (C14)
Specialization (C15)
Gender Male 40 100
Specialists (C16)
Female 0 0

Experience ≤10 years 6 15

+ 11–14 years 8 20
where v j = (1, 1, 1) and v j = (0, 0, 0).
15–19 years 10 25
20 ≥ years 16 40
+
Step 6: Compute the distances indicated of each alternative from v j City Johor Bahru 8 20
and v j using the following equations: Melaka 5 12.5
Penang 6 15
n +
d+i = dv(vij, v j ) Kuala Lumpur 21 52.5
j=1 (11)

5
M. Nilashi, et al. Computers & Industrial Engineering 137 (2019) 106005

Table 4 3.2. DEMATEL

Average matrix.
Technological Organizational Environmental Human DEMATEL is one the effective technique to find and analyses the
inter-relationship among the system factors. This method transforms
Technological 0.0000 1.5750 1.5250 2.5250 the causal relationships between the factors indicators into a tangible
Organizational 3.8500 0.0000 1.1500 3.0000
structural model. DEMATEL is a comprehensive method for the pre-
Environmental 2.1000 2.3250 0.0000 2.3000
Human 3.3750 2.7000 1.4250 0.0000
paration and analysis of a structural model that includes causal re-
lationships between complex factors. This technique acts on directional
graphs, and these graphs are able to display directional relationships
Table 5 between sub-systems. The result of the DEMATEL technique is to divide
The direct influence matrix. the factors into two cause and effect groups. The steps of DEMATEL
technique is a follows:
Technological Organizational Environmental Human

Technological 0.0000 0.1689 0.1635 0.2708 Step 1. The data is collected from the respondents. Suppose that
Organizational 0.4129 0.0000 0.1233 0.3217 there is H respondents and n factors, each respondent provide the
Environmental 0.2252 0.2493 0.0000 0.2466
effect of the factor i on factor j . These effects are presented in a
Human 0.3619 0.2895 0.1528 0.0000
matrix X k = [Xijk ]n × n (for the k th respondent). From this matrix, di-
rect relations matrix is formed. The scale ranging is from 0 (No in-
Table 6
fluence) to 4 (Very high influence). All elements aii in main diameter
The total relation matrix.
of Xk are 0. To have a combined matrix of all respondents’ feedback,
we use the following formula:
Technological Organizational Environmental Human
H
1
Technological 0.6197 0.6018 0.4528 0.7439 A = [Aij ]n × n = [Xijk ]n× n
H (15)
Organizational 1.1168 0.5924 0.5232 0.9438 k=1
Environmental 0.9015 0.7274 0.3615 0.8140
Human 1.0474 0.7900 0.5234 0.6669 Step 2: In this step, the normalized primary direct matrix is calcu-
lated. We call this matrix as initial influence matrix, D . To form a
normalized matrix of direct relations matrix, we use the following
Table 7
formulas.
Final results of DEMATEL analysis.
A
Factors R C R+C R−C D=
S (16)
Technological 2.4182 3.6854 6.1036 −1.2673 n n
Organizational 3.1762 2.7117 5.8879 0.4646 S = max(max aij , max aij )
Environmental 2.8045 1.8610 4.6654 0.9435
j=1 i=1 (17)
Human 3.0277 3.1685 6.1962 −0.1408

Step 3: We compute the direct/indirect influence matrix. This ma-

trix reflects the direct and indirect effects that the matrix elements
(factors) have on each other. L is an identity matrix. The total re-
lation matrix T is calculated by:
T = D(L D) 1
(18)

Step 4: In this step, two matrices C and R are calculated. These

matrices are constructed to form R + C (total effects given and re-
ceived by a factor) and R C (the net effects that a factor con-
tributes to the system). Accordingly, if R C is positive, the factor
is net cause, otherwise the factor is net receiver.
T = [tij]n × n i, j = 1, 2, n (19)

Fig. 2. Interrelationships among four factors of readiness and decision to adopt n

medical tourism by hotel firms. C=( tij)n × 1 i = 1, 2, n

j=1 (20)
n
n R=( tij)1 × n j = 1, 2, n
di = dv(vij , v j ) (21)
j=1 (12) i=1

1
d(x, z) = [(l x lZ )2 + (mx m z )2 + (ux uz ) 2] 3.3. Data collection
3 (13)

Step 7: Compute the closeness coefficientCCi, through the following In Malaysia, the Tourism Development Corporation (TDC) was in-
equation: itiated in 1972, which was responsible for the development of domestic
and international tourism (Ghani, 2016). Nowadays, the tourism sector
di is one of the major national key economic areas in Malaysia. With the
CCi =
d+i + d i (14) help of various private and public agencies, the tourism and hospitality
sector has contributed significantly to this country economic growth. In
Step 8: Compute the ranks of the alternatives according to CCi in 2017, the Malaysia’ investment on Travel & Tourism was MYR23.0
decreasing order. billion, 6.7% of total investment (USD5.3 billion). In addition, in 2017,

6
M. Nilashi, et al. Computers & Industrial Engineering 137 (2019) 106005

Fig. 3. The causal diagram for four factors of readiness.

Table 8 Table 10
Average rating for each criteria of technological readiness. Average rating for each criteria of organizational readiness.
Criteria Fuzzy rating Criteria Fuzzy Rating

Efficient Information Systems (C1) (0.73,0.83,0.92) Top Management Commitment (C5) (0.58,0.71,0.84)
Internet (C2) (0.65,0.77,0.88) Financial Performance (C6) (0.65,0.77,0.88)
Cloud Computing Technologies (C4) (0.42,0.59,0.76) Infrastructure (C7) (0.79,0.89,0.96)
Medical Technology (C3) (0.79,0.89,0.96) International Healthcare Collaboration (C8) (0.32,0.5,0.68)

Malaysia has achieved the GDP around MYR181.4 billion (USD41.9
billion), 13.4% of GDP, by contributing in the Travel & Tourism. Fur-
thermore, Travel & Tourism in Malaysia has directly supported 670,000
jobs (4.6% of total employment).
Established in 2009, Malaysia Healthcare Travel Council (MHTC) as
an agency under the Health Ministry has been responsible to provide
world class healthcare services and facilitate the medical tourism de-
velopment by building Public-Private Partnerships (PPP) and with the
coordination of industry collaborations. Malaysian government has
showed high interest towards the medical tourism in recent years. In a
report by the Malaysian Ministry of Health (MOH), it has been em-
phasized that the income from foreign patients can significantly en-
hance the national health services which can bring benefits for the local
population (Leng, 2010). The report of MOH shows that the number of
foreign patients to Malaysia has been increased from 393,000 to
770,000 between 2010 and 2013 with a huge rise in financial receipts
from RM379 million to RM690 million. Also, the report shows that
medical tourism will generate RM35.5 billion in Gross National Income
(GNI) and provide 181,000 new careers to cater to 1.9 million medical
travellers by 2020. The report of MHTC also demonstrated that the
income from medical tourism from an estimated 900,000 medical
tourists was RM1 billion in 2016. Such other countries which have
contributed to the medical tourism, there have been several hospitals
and clinics, listed in the Malaysian medical tourism website (www.
medicaltourism.com.my), to provide the medical treatments for the
people who come to Malaysia as medical travelers.
Although, the evidence shows that the medical tourism services in
Malaysia are growing, these services are only provided in some of the
public and private clinics and hospitals. In addition, small number of
major hotels solely provide spa and wellness services and other types of
medical services are not provided because of several readiness issues.
This study focused on the four major readiness factors for the im-
plementation of medical services by major hotels in Malaysia which are:
human readiness, organizational readiness, technological readiness and
environmental readiness. The target population of this research com-
prises the managers of hotels in Malaysia. We investigated their per-
ception and attitude toward medical hotels and the problems faced by
them in adopting this type of services. They were asked to provide their
difficulties on four factors, human, organizational, technological and
environmental factors. All details of major Malaysian hotels along with
their websites were found in www.tripadvisor.com. These hotels pro-
vide 5-star accommodations. In addition, we randomly selected those
hotels which provide Spa services to the customers. The sample char-
acteristics of the hotels managers are provided in Table 3. The data
collection is conducted in four cities in Malaysia, Johor Bahru, Melaka,
Penang and Kuala Lumpur. From this table, it is found that the majority
of respondents (52.5%) have been the hotels’ managers in Kuala
Lumpur. In addition, this table reveal that 40% of respondents have had
more than 20 years’ experience in hotel management for top-level
management responsibilities.

Table 9
The linguistic terms correspond to the average fuzzy scores of the technological readiness factors.
Criteria Distance between Linguistic Term and Factors Minimum Distance Linguistic Term

VL L ML M MH H VH

C1 0.76 0.627 0.479 0.338 0.182 0.027 0.108 0.027 H

C2 0.701 0.567 0.418 0.276 0.120 0.036 0.170 0.036 H
C3 0.814 0.68 0.533 0.391 0.236 0.081 0.054 0.054 VH
C4 0.529 0.394 0.241 0.093 0.062 0.218 0.352 0.062 MH

7
M. Nilashi, et al. Computers & Industrial Engineering 137 (2019) 106005

Table 11
The linguistic terms correspond to the average fuzzy scores of the organizational readiness factors.
Criteria Distance between Linguistic Term and Factors Minimum Distance Linguistic Term

VL L ML M MH H VH

C5 0.645 0.511 0.36 0.218 0.062 0.093 0.228 0.062 MH

C6 0.701 0.567 0.418 0.276 0.120 0.036 0.170 0.036 H
C7 0.814 0.68 0.533 0.391 0.236 0.081 0.054 0.054 VH
C8 0.442 0.307 0.152 0.016 0.152 0.307 0.442 0.016 M

Table 12 Table 14
Average rating for each criteria of environmental readiness. Average rating for each criteria of human readiness.
Criteria Fuzzy Rating Criteria Fuzzy Rating

Government Policy (C9) (0.65,0.77,0.88) Language and Communication (C13) (0.32,0.5,0.68)

National Healthcare Policy (C10) (0.54,0.68,0.82) Service Quality (C14) (0.54,0.68,0.82)
Investment (C11) (0.76,0.86,0.94) Specialization (C15) (0.76,0.86,0.94)
Facilitating Visits to Malaysia (12) (0.42,0.59,0.76) Specialists (C16) (0.82,0.92,0.98)

3.4. Data analysis and discussion
In this study, the data was collected form the 40 managers of major
hotels in Malaysia. An in-depth interview was conducted with each
manager of hotel before the data collection by a questionnaire survey.
In addition, to better be familiar with the questionnaire and how to be
completed, a guideline was prepared and the method of completing the
questionnaire was explained. In addition, we tried to explain them
about the methods of data analysis to be more aware about it, which
helped them in understanding the types of questionnaires used in this
study.
In the first step of data analysis, the DEMATEL survey ques-
tionnaires were distributed. The aim of this survey was to reveal the
interrelationships among four factors of readiness and to find the im-
portance level of them with respect to the managers’ decision to adopt
medical hotels in Malaysia. In this survey, the managers were asked to
provide their answers to the questions by the following scores: “No
Influence (0),” “Low Influence (1),” “Medium Influence (2),” “High
Influence (3),” and “Very High Influence (4)”. To perform the steps of
DEMATEL presented in the previous section, the data was structured in
the matrices for all respondents. In the first step of our analysis, the
combined (average) matrix A = [Aij ]n × n was calculated (see Table 4).
Then, by calculating the normalized primary direct matrix (see
Table 5), we could obtain the matrix T for all relationships (see
Table 6). After calculating this matrix, we obtained C , R , C + R and
C R from each matrix T (see Table 7).
The results of Table 5 can be depicted in a model which reveals the
relationships among the main factors according to the T values (see
Fig. 2). In this model, based on a threshold value which is calculated
from the average of the values in T matrix, the relationships are con-
structed. In fact, the significant relationships are presented in the model
by T values for influence rate. In Fig. 2, it can be seen that the influence
rates of environmental factor on technological, organizational and
human factors are respectively, T = 0.9015, T = 0.7274 and
T = 0.8140. In addition, the influence rates of organizational factor on
technological and Human factors are respectively, T = 1.1168 and
T = 0.9438. The results further reveal that the there is a significant
relationship between technological factor and human factor with the
influence rate of T = 0.7439. In addition, the outcome of DEMATEL
analysis showed that Human factor has no impact on the technological,
environmental and organizational factors for decision to adopt medical
hotels in Malaysia. In Fig. 3, the causal diagram for four factors of
readiness is presented. This figure better shows the importance of the
factors based on the results of Table 6. In fact, this figure show that
technological, organizational, environmental and human factors are
respectively net receiver, net causer, net cause and net receiver with
R − C values of −1.2673, 0.4646, 0.9435 and −0.1408. In addition,
the result of R + C in this figure shows that technological and human
factors are more important than organizational and environmental
factors for decision to adopt medical hotels in Malaysia.
After data collection through first questionnaire, Fuzzy TOPSIS
questionnaire was distributed which were designed based on 7 scales,
“Very Low (VL)”, “Low (L)”, “Medium Low (ML)”, “Medium (M)”,
“Medium High (MH)”, “High (H)”, and “Very High (VH)”. Based on
these linguistic scales, the experts provided the importance of each
factor of the decision making model. In Tables 8–15, we present the
average scores and the linguistic terms correspond to the average fuzzy
scores of the technological, environmental, organizational and human
readiness factors. The results of Fuzzy TOPSIS analysis for final ranking
are presented in Table 16.
4. Discussions
Tourism has been one of the important economic activities in the
developing and developed countries around the world (Nilashi et al.,
2018). As a developing country, Malaysia's economic growth has
caused a rapid rise of tourists’ arrival. Regarding medical hotel devel-
opment, the evidence shows that the trend of medical hotel in Malaysia
is still in its early stages compared to the developed countries. In ad-
dition, despite a growing body of research in the field of tourism and

Table 13
The linguistic terms correspond to the average fuzzy scores of the environmental readiness factors.
Criteria Distance between Linguistic Term and Factors Minimum Distance Linguistic Term

VL L ML M MH H VH

C9 0.701 0.567 0.418 0.276 0.120 0.036 0.170 0.036 H

C10 0.616 0.481 0.330 0.187 0.031 0.124 0.259 0.031 MH
C11 0.787 0.653 0.506 0.365 0.209 0.054 0.081 0.054 H
C12 0.529 0.394 0.241 0.093 0.062 0.218 0.352 0.062 MH

8
M. Nilashi, et al. Computers & Industrial Engineering 137 (2019) 106005

Table 15
The linguistic terms correspond to the average fuzzy scores of the human readiness factors.
Criteria Distance between Linguistic Term and Factors Minimum Distance Linguistic Term

VL L ML M MH H VH

C13 0.442 0.307 0.152 0.016 0.152 0.307 0.442 0.016 M

C14 0.616 0.481 0.330 0.187 0.031 0.124 0.259 0.031 MH
C15 0.787 0.653 0.506 0.365 0.209 0.054 0.081 0.054 H
C16 0.840 0.707 0.560 0.418 0.263 0.108 0.027 0.027 VH

Table 16
Final ranks of criteria of decision making model.
Factors Criteria di d+
i
Closeness Coefficient (CC) Criteria Rank

Technological (D1) Efficient Information Systems (C1) 0.848 4.156 0.169 2

Internet (C2) 0.788 4.22 0.157 3
Cloud Computing Technologies (C4) 0.622 4.398 0.124 4
Medical Technology (C3) 0.901 4.103 0.180 1

Organizational (D2) Top Management Commitment (C5) 0.751 4.259 0.150 3

Financial Performance (C6) 0.806 4.202 0.161 2
Infrastructure (C7) 0.919 4.085 0.184 1
International Healthcare Collaboration (C8) 0.542 4.484 0.108 4

Environmental (D3) Government Policy (C9) 0.821 4.188 0.164 2

National Healthcare Policy (C10) 0.733 4.282 0.146 3
Investment (C11) 0.910 4.094 0.182 1
Facilitating Visits to Malaysia (12) 0.647 4.376 0.129 4

Human (D4) Language and Communication (C13) 0.534 4.491 0.106 4

Service Quality (C14) 0.703 4.311 0.140 3
Specialization (C15) 0.875 4.130 0.175 2
Specialists (C16) 0.927 4.076 0.185 1

medical tourism, there is a limited research on the development of
medical hotels in Malaysia.
This research has taken an important step toward filling this gap in
medical hotel by identifying the most important challenges faced by
hotels’ managers in Malaysia. We found that the most hotels in
Malaysia are not ready to provide medical hotel services because of
several issues such as human, environmental, organizational and
technological challenges. This study found human as one of the most
critical readiness factor for developing medical hotels in Malaysia.
Among language and communication, service quality, and specializa-
tion and specialists criteria in human factor of readiness, managers of
hotels are more concerned about the shortage of medical manpower
(specialists) and specialization (specialized treatments). They believe
that a shortage of medical manpower has significantly impacted on
their decision to provide medical hotel services.
With respect to the environmental factor of readiness, the hotels’
managers are more concerned about the investment and government
policy. This indicates that sizeable investments are needed to
strengthen, upgrade and expand the medical hotel services in Malaysia.
In addition, more qualified specialists are needed for medical hotels
services which need partnerships between hotels and hospital investors.
Furthermore, government policies play an important role in estab-
lishing medical hotels in Malaysia. Lack of governments’ involvement
can be a significant obstacle in developing this type of tourism, in-
dicating that government’s role in establishing the medical hotels
should be reiterated through new policies to increase the budget for
medical tourism. In addition, Malaysian Health Ministry supports can
encourage the private providers of healthcare to invest on medical
hotels with more motivations. Furthermore, to setting up medical hotels
by the managers of hotels, policies are needed aimed at decreasing the
expense of equipment and facilities, and attracting and supporting the
overseas investmentors in medical tourism to promote medical tra-
veling and tourism.
With respect to the technological factor of readiness, the hotels’
managers reveal their concerns on the medical technology and efficient
information systems. Medical hotel service providers such other
healthcare service providers need efficient information systems and
medical technology, as sharing the medical tourist information is per-
formed electronically among the organizations. In addition, collabora-
tion between the healthcare and tourism sectors needs adequate in-
formation processing technologies such as electronic medical records
processing systems and telemedicine for the communication purpose
(exchanging emails between the specialist and the patients), e-con-
sultations and e-diagnoses.
With respect to the organizational factor of readiness, financial
performance and infrastructure are considered as two important en-
ablers of medical hotels. From the financial performance perspective,
tourism organizations must consider enough budgets to be able to
provide the medical hotel services in a comprehensive way. In addition,
medical hotels providers need sufficient infrastructures such as physical
environment, supportive facilities, and separate private and public
clinics and hospitals to support medical tourism and provide medical
hotel services. These infrastructures need huge amount of support from
the private sectors and government. This indicates that scarcity of land,
high land costs, limited access to financial facilities and budgetary al-
location can significantly influence the managers’ decision to establish
medical hotels in Malaysia.
5. Conclusions and future study
In this research, the attempts have been made to develop a decision
making model for the adoption of medical tourism in Malaysia. The
decision making model included several factors and criteria which were
identified from the literature. We employed two multi-criteria decision
making model to achieve the objectives of this research, DEMATEL and
Fuzzy TOPSIS. In the first stage of the data analysis, we employed

9
M. Nilashi, et al.
DEMATEL to reveal the interrelationships among the readiness factors.
In fact, the DEMATEL techniques could effectively reveal the influence
scores of technological, organizational, environmental and human
readiness factors. In the next stage of our data analysis, we employed
Fuzzy TOPSIS to find the importance of each criteria in the decision
making model. The results from DEMATEL data analysis showed that,
from the managers’ perspectives, that technological and human factors
are more important than organizational and environmental factors for
decision to adopt medical hotels in Malaysia. The results further re-
vealed that human factor significantly received influence (net receiver
factor) from the technological, organizational, and environmental fac-
tors. The results of Fuzzy TOPSIS further revealed the importance of the
criteria in each factor. The data analysis results indicated that medical
technology and efficient information systems are more important for
technological readiness. In addition, infrastructure and financial per-
formance are more significant for the adoption of medical tourism in
Malaysia. Furthermore, investment and government policy are found to
be more important in environmental factor. Our results also found that
specialization and specialists are more important for human readiness.
This research is not without theoretical and methodological lim-
itations. In this study, a limited number of readiness factors are in-
vestigated for the adoption of medical tourism in Malaysia. Future
studies may further investigate the role of other factors (e.g., culture,
medical insurance coverage, global competition, transplantation law) in
this context. In addition, this study was conducted from hotels man-
agers’ perspectives. Other studies can investigate the issue of medical
tourism adoption from the tourists’ perspectives. Furthermore, this
study used multi-criteria decision making approaches for factors as-
sessment. The future studies can find the relationships between the
factor using Partial Least Squares based Structural Equation Modeling
(PLS-SME) and compare the results with the results of the techniques
used in this study. Moreover, this study used HOT-fit and TOE frame-
work to develop the adoption model. Other organizational theories are
suggested to be investigated in the future studies. Finally, the sensitivity
analysis is suggested for the future studies to show the robustness of
Fuzzy TOPSIS and its results by changing the criteria weights in dif-
ferent scenarios.
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